A new online auction begins tomorrow to benefit the Joseph M. Smith Community Health Center. The auction will run from January 1 to January 7. You can sneak a preview here, but you can't bid until 6am on New Year's Day.

Health Leaders Media listsEngage with Grace as one of 10 phrases that became part of the health care lexicon in 2009. I'm sure our blog rally propelled it up there. It is a lot more useful than most of the other expressions, I say.

Wednesday, December 30, 2009

This is for soccer players, parents, fans, and, of course, referees. There are few things more challenging that officiating a game with 22 players running across a field that is larger than 5000 square meters, lasting at least 90 minutes, where your job description is to decide in real time whether a foul is meaningful enough to warrant your interrupting the flow of the game. (Compare this to other games with more umpires on a smaller field, where a foul is always called and then, during the stoppage, a judgment is made as to whether a penalty will be awarded.)

Soccer referees take an initial course to become certified, are regularly assessed during games, and then are required to take an annual recertification course during the off-season. Here's a video clip of a course last weekend. Segments of the class include a written test, followed by discussion of the possible answers. Then the group breaks up into smaller groups to evaluate a particular scenario and report back to the full group. During breaks, you can go to the Soccer Spot table and purchase supplies and equipment for the next season.

Everybody's favorite part, of course, is watching film clips of actual game situations and judging the appropriate call. I have given you some to watch, and you can make the call. They start at minute 2:23 of the video.

I'll give you a hint about one. The scene in clip 3 (minute 2:50) is not a foul. Think about explaining that to the coach of the striped team or to the parents of that young lady lying on the ground.

Very funny status update on Facebook from my Indian friend and comedienne, Dhaya:

Stay tuned for craziness. Parents arrive tomorrow. They are bringing "The Mister". After a moment of potential arranged marriage panic, I realized they were referring to a recently acquired humidifier they want to give me. Mist away Mister!

Friday, December 25, 2009

Our Chief of Medicine, Mark Zeidel, and his wife, Dr. Susan Freedman, have a tradition of holding Christmas morning breakfast with the residents on duty at the hospital.

On the east side of the campus, the spread consisted of bialies, bagels, and smoked salmon from Kupel's Bakery in Brookline. Shamshad Zahoor, from Environmental Services, jumped in unasked to help clean up the table. Mark then made the rounds telling people on each floor that breakfast awaited. Not surprisingly, they responded.

Meanwhile, on the west side, a crew had begun to make pancakes for their colleagues. Residents Kelly Bodio and Stephanie Mueller called in reinforcements, Stephanie's husband Matt Ledoux, to keep up with the demand. Violet, dressed for the season, patiently awaited her portion.

Thursday, December 24, 2009

Helen, seen here, is 97. Get her started on how to make filo dough, or any other topic, and you are in for a story. Her specialties tonight included pastitsio (Greek lasagna) and baklava. Her daughter Joan is no cooking slouch either, with a lobster shepherd's pie based on an old recipe from The Elms Inn, in Ridgefield, CT. Other guests brought the salad with pine nuts and the kumquat tarts. An excellent feast!

Santa, accompanied by some kind of reindeer, was seen this afternoon on Commonwealth Avenue. This is the real thing: Listen closely when about 53 seconds have passed and you will clearly hear his "Ho, Ho, Ho, Ho!"

Wednesday, December 23, 2009

The article was wrong about one thing, perhaps reflecting a social-media induced change in social morays with regard to privacy:

There is also a privacy issue with Twttr. Every user has a public page that shows all of their messages. Messages from that person’s extended network are also public. I imagine most users are not going to want to have all of their Twttr messages published on a public website.

I had just about digested the gelato when these cookies arrived today from a friend. His note said, "The tin is filled with handmade cookies made by an artist friend of mine in P'town. This is a reward for all your biking and exercise, so enjoy!"

Continuing our non-health care holiday theme, it's time to focus on food. I have lost track of the holiday parties during these last two weeks -- seemingly one for each department in the hospital, not to mention the various affairs around town. All these represent a difficult obligation for us CEOs. But with practice, you adapt.

In a non-institutional vein, I take pleasure in reporting on an intimate dessert party last night at the home of Eduardo Kreindel, Gelato Master of Giovanna Gelato. Eduardo gave up a career in architecture to learn authentic Italian procedures for making gelato and sorbet. He grew up in Argentina, which has a huge Italian population, and he is now fulfilling a dream designing and producing lots of flavors.

Here is a picture of Eduardo in his kitchen, where he explained the equipment and ingredients he uses. The cookies are not part of that. They are an Argentinian treat called "rumbas," which go very well with gelato.

Eduardo often conducts tastings at local grocery stores. Bostonians and Rhode Islanders can find samples next week at the Harvest Coop in Jamaica Plain on December 28 and the East Coast Market in Providence on December 29. Click on the photo to get details of the tasting list! ("DDL" = dulce de leche.)

Tuesday, December 22, 2009

Easing into the holiday week, a change in topics from health care. One of my favorite shows on television is This Old House, and in that I am joined by lots of people who have watched the show for 30 years.

My administrative assistant somehow wrangled a way for my wife, my brother-in-law, and me to visit the current TOH site in Roxbury, a neighborhood of Boston. We were hosted by VP for TV Operations Michael Burton and welcomed by developer David Lopes. Seen here flanking the family members are Senior Series Producer Deb Hood and director David Vos. The renowned Norm Abrams is in the middle.

We had a chance to see the filming of a short segment regarding the installation of a mantle and an old-style cast iron front piece that would be used for a coal-burning fireplace (in this case an ornamental one only). I prepared this short video to give you a sense of the logistics involved in what will be just a short segment. I am sure this doesn't compare to the camera work of TOH cameraman Dino D'Onofrio! You can compare this to the final production when the show is aired in late January.

Last week, I sent this staff email following up on our earlier announcement about the new clinical partnership between Atrius Health and BIDMC. It gives you a sense of how we are preparing for this joint venture, but also provides the broader context. Gene Lindsey's comment holds even more power in light of the direction of recent legislative activity in Washington, DC.

Dear BIDMC,

As you may have read a few weeks ago, Atrius Health and BIDMC have entered into a new patient care partnership. Starting January 4, patients from the Harvard Vanguard Kenmore, Copley, and Post Office Square Centers will be coming here for emergency care and tertiary care. We have had teams from both organizations working for months on the logistics and planning for this, and we are in good shape to proceed. (For example, read John Halamka's blog for details of some of the items involved in the IT arena.)

We had a welcoming reception last night in the Shapiro lobby, and it was a great chance for clinicians, administrators, and board members from both institutions to get together and to celebrate the work that has gotten us this far. It was striking how many of these folks already had relationships, some dating back to their training days.

Over the coming days and weeks, you will see some new people from Atrius on our floors as this rolls out, especially hospitalists and case managers, but also people in specialty areas. I know you will make them feel welcome.And I am absolutely confident that patients from Atrius will see the same level of care we strive for all the time, the kind of care we would want a member of our own family to receive. But, we want this to be more:

Gene Lindsey, the Atrius CEO, and I have met with each other's senior management team, and we have a simple and a hard message for both organizations. We aim for this partnership to set a new standard for patient care in the region. As a tertiary center, we plan to be exceptionally responsive to the primary care-centered model of care exemplified by Atrius(and also enhancing how we do so with our own superb primary care practices at Healthcare Associates, APG, and the community health centers). Together, we look forward to setting higher bars in safety and quality, aided by transparency. We will also work together using the philosophy, measures, and techniques of the Lean process to improve the work environment for all.

(In that regard, I am officially declaring the end of BIDMC SPIRIT, which was an inward-looking approach to process improvement. SPIRIT was based on Lean principles, and we learned a lot from it. But we now start to enter a different phase of process improvement, one based on JOINT action with our clinical partners, starting first with Atrius. In the last few months, Alice Lee and her team have been teaching us more about Lean. Many of you have participated in rapid improvement events and other training. That will continue, but, in Atrius, we have a partner who has been engaged in similar training, and we aim to learn from one another and apply this philosophy to our joint operations.)

More broadly, Gene recently addressed aspects of our mutual goal in a newsletter to his staff. He noted:

“How do we reform healthcare?” That is a big tough question. This week I heard Don Berwick from the Institute for Healthcare Improvement point out that the question in Washington has shifted toward, “How do we reform health insurance?” By changing the question, the President is indicating his understanding of the limits of legislation. He understands that politicians can change the way people access care, or how care is financed, but they cannot change how care is delivered and legislators will always find it difficult to create quality.

Politicians can increase the funding of health care, but a reform of the practice of healthcare is our domain. Only we, the community of practice, can improve quality and change the systems of care in such a way as to improve the experience of care for individuals, improve the health of the nation and end the extortion of much needed funds from the other categories of our collective societal experience. Only we, the good people who provide the care, can create the solutions that end the fragmented, mediocre and unsafe experience of care that is the experience of so many of our citizens.

We control the experience of health care for our patients far more than we might want to admit. Since so often they do exactly what we tell them to do when we suggest a test, or a surgery, we need to be very sure that we try to see the world as they do as we give them our counsel. Being patient-centered is the hardest task we have because for many of us it means trying very hard to convince patients that they should do what we think is best.

What gets done is usually what we order. The options that most patients have are the ones that we offer. Their experience of care is the experience we provide. If we care about our patients, the first question that must be answered is “What do they really really want?”

Note that the focus here is what patients really want. They do not want MRIs, CT scans, or procedures. They want to live happy and healthy lives. They want us to listen to them and understand their needs. This was put so clearly by Dr. Amy Ship, when she recently accepted the Compassionate Caregiver Award from the Schwartz Center. Please take 8 minutes to watch and listen to Amy's speech, here.

Gene and I are excited about the Atrius-BIDMC partnership because we think it provides a vehicle for learning how to do this and for spreading the word to our community. We invite you to join this adventure and be active participants.

Many thanks to those of you who participated in my recent auction to benefit the Bowdoin Street Health Center. Remember that we were trying to raise money for an ultrasound machine, so pregnant women could have ultrasounds in their neighborhood setting rather than having to spend time and money to travel to BIDMC for this service.

I received good news today from Adela Margules, who heads the center:

I wanted to let you know that I received notice today that we have received a grant from the MA Health and Educational Facilities Authority to help purchase an ultrasound machine for our ob/gyn practice. (HEFA has a competitive grants program each year for health centers, and we were one of 14 funded.) This grant award, coupled with the funds raised through the Red Sox raffle* and the auction on your blog, allows us to move forward and purchase the machine.

A "benefit" of being a CEO is that publishers send you copies of all the new management books, presumably so you will recommend them to your colleagues. Most are not very good. If you are lucky, a book will have one good idea that is stated in the introduction or first chapter. Then they fill the book with poorly edited repeats of the same concept. Often, they use a large font so the book will have more bulk.

This week's book is by Quint Studer and is called Straight A Leadership: Alignment, Action, and Accountability. (Fire Starter Publishing, Gulf Breeze, FL) I skipped the first two topics but found the chapter on the third. I have been thinking a lot about accountability and was curious to see what he said. The crux of his case was, "What we find is that most organizations fully grasp the importance of accountability, and they put guidelines into place to hold people accountable to -- but somehow, they fall short of closing the loop."

Over the past few months, I have come to a conclusion about accountability that is at variance with most management guidance on the subject. That guidance suggests, as in Studer's book, that a successful organization depends on holding people accountable to do good quality work in support of corporate objectives. I'll assert instead that it is not only impossible to hold people accountable in an organization, but trying to do so is a misallocation of managerial attention.

You say, "What? How will you make sure people are performing up to spec if you don't hold them accountable?"

I view the job quite differently. I view the leader's job as helping to create an environment in which people are so comfortable with their role in the organization, and are given the right tools for doing their job, that they hold themselves accountable. After all, most people want to do well in their job and want to do good in fulfilling the values of the enterprise. Why not trust in their inherent desire to be successful personally and collectively? Instead of focusing on measuring their performance against static metrics, why not create a setting in which they use their native intelligence, creativity, and enthusiasm to solve problems in an inevitably changing environment? Then, spend your time praising them and making sure they get credit. (See John Toussaint's and Paul O'Neill's thoughts here for variations on this theme.)

People who have heard my speeches know that I often make analogies between running a hospital and coaching a girls soccer team. (Regular readers know this all too well!) Your purpose as coach is not to criticize by pointing out errors and areas of deficiency. The players (workers) already know when they have made a mistake or are not performing up to par. Your task, instead, is to give them the chance to learn tools that enable them to meet a high standard, both individually and as a team.

I'll stop here for now on this topic and take your comments on my premise and on how it feels to work in your organization. Do you know what your role is, individually and with respect to the institution's objective and values? Are you respected and treated with dignity, regardless of your position in the organization? Are you given the tools you need to do the job? Are you recognized for what you have done?

I'll be the first to admit that our hospital leadership team still falls short in many respects. We are trying hard, but we are neophytes in this new mode of management. We need to learn to listen better so that we can be better coaches. Our goal, though, is to make it possible for each person to answer these four questions with a resounding "Yes." If we can do that, there will be no need to hold people accountable.

Sunday, December 20, 2009

A lot of us are otherwise pretty sensible - even risk-averse - people. So what happens to us when we get behind the wheel?

I put that question to Dan Ariely, a behavioral economist at Duke University, and the author of a book called “Predictably Irrational.’’ Last semester, he asked the 200 students in his class if they ever texted while driving. All but three raised their hands - and one of those three is blind.

But this is an even better one. It is a public service announcement to being shown in the UK to schoolkids. Warning: It is VERY graphic.

Please show it to your kids. Please watch it yourself.

Now, try this out. Look in your rear view mirror during an average commute and see how many people driving behind you are texting. You might be surprised.

My young neighbor Miriam is raising chickens in her backyard. With the blizzard arriving, her dad Jason had to do some emergency reinforcements of the chicken pen. I paid a visit this morning and picked up these images of the farming life going on just down the street in our suburban community.

If you cannot see the embedded version of the video here, you can follow this link to view it on You Tube.

Saturday, December 19, 2009

Regular readers know of my odd fixation about infrastructure. I can't help it. I just notice things about the streets, bridges, pipes and power line and wonder how and why.

Here's the latest, and I am hoping someone can explain. The Town of Brookline recently repaved Longwood Avenue. Then they painted these dashes on the road. I can't figure out what they are for. They clearly do not delimit a bike lane. Are they meant to provide a guide to drivers as to the appropriate position in this lane? If so, they don't quite work, as seen in the video. If you cannot view this embedded video here, you can use this link to YouTube.

I'll say one thing for the SEIU. It is consistent in its ability to be inappropriate to the situation and to resort to personal disparagement when it fails to persuade.

The setting: An annual Christmas party at which a group of us former members of the Boston Symphony's Tanglewood Festival Chorus get together with other friends and relatives to eat, drink, and sing Christmas carols.

A man introduces himself as a neighbor who works for the SEIU. We start with a little repartee about Blue Mass Group, where he notes that I was taking some hits for recent comments. I say how I love BMG as a democratic place where anybody can participate. He looks at me oddly.

He then sidles into the topic of, "When are you going to let your employees form a union?" I respond with, "When are you going to let them have elections with debates?" And the race to the bottom is on. Pretty quickly, I say, "Look, I'm here for a party with friends, not to discuss this stuff."

He says, "I think you're a hypocrite."

Let's see. We have known each other for about 90 seconds. We have quickly figured out that we are not going to persuade each other on the merits of the issue. So he resorts to a character slur.

I'll admit that my response at that point consisted of a rude, physically impossible, autoerotic suggestion. (I then apologized to my host for swearing at one of his guests.)

The rest of the evening was entirely pleasant, with lots of joyful singing. This fellow didn't join in.

In our E/R, we routinely draw blood for lab work off of IV starts. We do this to speed results and to spare the patient an unnecessary stick.

Our administration recently asked us to write a policy to define our procedure and best practices. In an extensive literature search, I came across a piece about this very topic in Paul Levy's "Running a Hospital" Blog. ("Fixing bad blood tests", dated 11/5/2008)

We will probably do an internal study similar to that described in the blog. Any information about the procedures or data from your study would be helpful to me. If you formulated a formal policy as a result of the study, I would very much like to get a copy.

Can you help me, or refer me to the people at your hospital who conducted the study?

Here is an in-progress report from Jean Campbell, nurse manager of our surgical intensive care unit, to all of the people in those units on the status of her Lean team's rapid improvement event in the SICU supply rooms.

Hi Team,

As you could see, there was a lot of activity in the clean supply room this week. The Lean team from the President’s Office, Distribution plus Anna (PCS), Sabrina (Health Care Quality), Martha (11 Riesman), Tim (MICU), (Fin4), and Kristin Russell worked with the SICU team to redesign the clean supply room for better flow.

We received training on key Lean principles and Smart Placement which taught us that spending time searching and fetching items means less time spent on real work – time with our patients. Even when we can easily find an item, does it make sense for us to put items out of reach, i.e. too high or too low? Why not imitate the supermarkets that place frequently purchased items, like bread, at eye level!

Lean calls these non-value added steps, “waste”. We spent the week removing as much waste out of the clean supply room process as possible. A few weeks ago we counted the par stock right after it was fully stocked, then counted again the next day before it was restocked. This gave us a single day usage quantity and was used to determine the amount needed on your supply room carts (called the par number). Our aim was approximately a 3-day supply (for weekends). We realized we had more stock than we needed in some cases and not enough in other cases based on this count, so we removed all excess stock as well as added additional stock where needed.

Once we regained additional space, we organized the stock logically by function and for flow. For example, you will see we now have carts for IV/Lab/Syringes/CRRT; GI/GU/Wound Care, ADLs, Procedures, and Respiratory. We then placed the most frequently used items at eye level to reduce bending and reaching and items used together are placed together. For example, you'll find benzoin on the respiratory cart because it's used when securing ET tubes. Most items are now in bins and the bin sizes indicate the amount of stock needed. The bins have 3 labels: the “common name or AKA (also known as) label” on the front of the bin – what most of you call the item, the “picture of the item label” on the bottom of the bin to tell you when that bin is empty what belongs there, and finally the “reorder label” also on the bottom of the bin that tells you the J number, cost & the ordering amount so when you are out of an item, you have the information needed when calling distribution. On the front of the shelves are the bar codes that distribution uses to facilitate reordering.

Some examples of changes:Procedure supplies that were formerly housed in cabinets in front of the nurses' station are now on the procedure cart (neuro on bottom shelf);Oxygen delivery items now have pictures to clearly show which mask is in each bin so you don't have to search very long;Wound care supplies were moved from the small carts in the middle of the unit to the supply carts. An added benefit is that it clears some of the corridor space - helping us meet CMS fire/safety guidelines;By placing procedure supplies and wound care supplies on the carts in the back, the UCo and RN don't need to worry as much about inventory and restocking. The exceptions will be items with pink AKA labels. Those must be special ordered; they don't come from distribution;IV Fluids with KCL have a highlighted AKA label to make it easier for you to find them;Med rooms and kitchens have also been reorganized.

We'll be establishing a location for distribution pick-up and drop-off - more to come on this. It will be an area where distribution can place items that are special requests and we can place items that need to be returned. You'll have an alphabetical index by Friday. Names of the carts are on the wall above them, so that will help you figure out where to start looking. It's meant to be intuitive.

Please let us know if there are items that are running low; this will be especially important on the weekends. We'll be doing regular audits to help us identify items that may be over or understocked and adjusting levels accordingly.

Help us help YOU! There's a piece of paper inside the supply rooms where you can provide feedback. Please include the date and your name so we can follow up if we don't understand and to let you know what the Lean team decides re: suggestions.We're also soliciting ideas with what to do with drawers/cabinets cleared through this event. We're investigating the possibility of placing monitors on shelves and using drawers/cabinets to sort cables.

Any other brilliant ideas out there?

Sustaining the gains: Lean taught us that this is a continuous improvement process so please give us your feedback and we will continue to improve. All of us own this process and keeping the Clean Supply room neat and tidy depends on all of us.

For trips between Boston and New York, there is nothing like the Amtrak Acela Express. It is convenient to downtown in both cities, comfortable, reliable, and quick.

Well, maybe too quick.

Several days ago, I posted a comment on Universal Hub and a helpful person replied with the website for Amtrak customer relations. So, I sent in the following note:

I am worried about the driver of the 4pm NYC-Boston Acela train exceeding the speed limit on the segment between Providence and Rte 128. It is a running joke among the porters that he is always in a hurry to get home. I have now seen this happen several times on that train. Last week, when I took it (Dec 1), you could actually smell the asbestos in the back car as he had to jam on the brakes before going over one of the bridges. I hope someone looks into this before the NTSB has to do so as part of an accident investigation.

Here was the response:

Thank you for contacting us. We have forwarded your e-mail to our Customer Relations Department. They will contact you as soon as possible in the order that the e-mail was received. Due to higher than normal volume, please allow up to 4 weeks for a response.

From the spouse of a patient. This hit home to me in that my mother died several years ago of a similar injury while on this anticoagulant. Although we didn't have a harpist while we awaited her death at New York-Presbyterian, we had a similar experience with marvelously caring staff. We, too, were grateful.

C's fall early in the morning was unwitnessed so I cannot say whether a dizzy spell or loss of balance caused it. He hit his head very hard against a sheetrock wall and the Coumadin regime proceeded silently to steal him away from me. The final 24 hours arrived with shocking suddenness. C was restless in bed and within fifteen minutes his eyes closed and he was unresponsive. The emergency crew arrived minutes after. From home to [the local hospital]; then by helicopter to Beth Israel Deaconess, arriving there around 9:30. I had to crawl my way through Boston commuter traffic and arrived at C's bedside at 11:00am. From that point forward the end was known, and I kept a vigil with my beloved until his passing around 2:45am the next morning.

The staff at Beth Israel Deaconess were wonderful. Every possible comfort was provided for C and me, including a harpist in our private sanctuary/room. She is a social worker and very gifted on the Celtic harp. C loved good music and after a half hour or so of beautiful selections C's breathing settled into a more accepting rhythm. Given the givers, it became a fairly stressfree death. What more could I pray for for a loved one?

A short video of our harpist follows. If you cannot view the embedded video here, you can follow this link to see it on YouTube.

Thursday, December 17, 2009

So, Mom is taken to the ED over the weekend for treatment of an infection. On one side of the room is the computer terminal for EMR access, with ever-changing screen savers touting the benefits of using the electronic record: safer, faster, more accurate, easier for the provider, better for the patient, etc. On the other side of the room, connected to Mom, is the electronic vital sign monitor: heart rate, blood pressure, oxygen, etc.

Half a dozen times, the tech came in to record her vitals. The procedure is: Put on one blue latex glove, take a Sharpie, write down the vital signs on the back of the gloved hand, leave the room, repeat a few hours later.

Does the blue glove go into the paper record? I dunno, but I guess the fancy EMR and the fancy electronic monitor don't talk to each other, because we have to rely on double manual transcription to record vital signs.

By the way, they use the same procedure up on the floor. Plenty of opportunity for improvement in health care.

Wednesday, December 16, 2009

In addition to the Marshfield High School performers, we were fortunate also to have a visit this week from members of the Tanglewood Festival Chorus, who performed some holiday songs in one of our public spaces. Here is an excerpt of an unusual version of the The Twelve Days of Christmas. While listening, try to catch a glimpse of my wife Barbara, a veteran chorus member, who arranged for the performance to be held for the benefit of our patients and staff. (If you cannot view the embedded video here, follow this link to see it on YouTube.)

Many people around the country followed the dramatic story last March when our employees generously gave up salary increases and benefits to help save hundreds of jobs of their fellow workers. A key part of that process was that staff members had multiple paths to contact me with suggestions and reactions to various proposals. Thousands of people did that, and it was very helpful as I made decisions on these matters.

Several months have passed, and our financial situation has improved. We hope to be close to the time when we might restore salary increases and/or benefits. I needed to know which of those items would be most important to our workers, to help set the priorities for restoring them.It was time to check in again.Two emails follow. I sent out the first just before Thanksgiving and the second one yesterday.

As I have talked about all this with people around the country, many have expressed surprise that, as CEO, I would "take the risk" of consulting our staff on these matters. For some, this is considered an odd ceding of executive authority. My view is just the contrary. If a CEO cannot rely on the judgment and opinions of those doing the work in an organization to help him/her make the final decisions on matters affecting those very people, what does it say about the level of mutual respect in that institution?

Here's the first email:

Dear BIDMC,

As Thanksgiving approaches, it is good to remember that we are blessed to work in a place devoted to healing and characterized by mutual support. Our collective decision in March to adopt a different approach to balance our budget to avoid what might have been hundreds of layoffs is consistent with our deeply held values. It brought national and regional acclaim to our hospital and to those of you who work here. I am proud of your participation in making those decisions during that difficult time.

But that does not mean everything is easy. Here is a representative note from Carol:

I am writing you to express my concerns after reading the Annual Operating Plan where it says that we want to "Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs to prepare employees for jobs in areas facing skills shortages, and leadership development programs to enhance the strength and capabilities of our managers."

My concern is that it may become harder to recruit and retain “outstanding people” with the loss of benefits. Everyday we all go to the grocery store, the gas station and pharmacy and pay more for the things that we need, not want but need. I would appreciate any feedback in regards to the time frame of reinstituting some our lost benefits.

In talking to my colleagues I find that I am not alone in these concerns. At this point it seems that the surrounding hospitals are better compensated then we are. The difference between them and us is that we have a dedicated and loyal staff.

Here was my short answer, but I am writing to give you a longer one and, once again, to ask your advice:

Thank you, Carol. We are working to restore the benefits as soon as possible. More to come on that front. I do not believe our compensation is out of line with other hospitals, but I do know that we laid off many fewer people than those hospitals because of the sacrifices that everyone here participated in. That was the choice before us, for which we and the staff here received tremendous credit. If I were to make the choice again, I would do the same thing.

So, what's going on and what are our plans?

What's going on is that we ended the fiscal year on September 30 with a $10 million operating margin for the year, much better than the $20+ million loss we were projecting in March. Frankly, through the spring and summer we were just on a pace to break even, but then we had a few lucky one-time events in September (like a commercial dispute that went our way) that were pleasant surprises.

For FY2010, we are budgeting for a 2% operating margin, or about $30 million, but that is based on retaining the same sacrifices in salary and benefits that we discussed back in March. That margin is less than we would like, in terms of our investment needs in physical plant and equipment, but we can get by.

Here's the issue we face right now. The economy still stinks, with a 10% unemployment rate, reduced consumer spending, and the like. It is really hard to know how we will fare in that kind of environment. Is there really an economic recovery about to happen, or will the region slide further down? Will the governor be forced to cut Medicaid payments again? What will Congress do with Medicare as part of health care reform?

So, how do we answer Carol's question? When should we go back to business as usual and restore salary and benefit cuts?

We have an agreement with our Board that we can start to restore those cuts if our operating results for the year show a consistent pattern that is better than our budget. A consistent pattern is something we would see in mid-January, based on our operating results through December.

Let's assume the best! In preparation for what might be, I'd like your help to plan our actions.

The question is this. If and when we are able to start to phase in the things we took away, which would you like to get back first?

Restoration of ET timeRestoration of the 401(k) matchRestoration of the annual merit salary increases

...You can write me directly, but also please respond on this survey instrument so we can get the overall view from lots of people. Click here between now and Monday at 5pm: [link omitted]. I'll post the results on our portal. Your opinions will be one input into my decision on the matter.

I will let you know that decision, and I will also provide you with the specific financial metrics that would trigger the decided-upon restoration of benefits and/or salary increases. I will keep you informed as the weeks go by of our progress towards those metrics, and you will know -- as soon as I do -- when things will be restored. That seems most fair to me: You have a right to know as much as I do on this matter, and you have my commitment that everything will be presented to you in a clear and open way.

Best wishes for a happy holiday for you and your family.

Sincerely,

Paul

Here's the follow-up email:

Dear BIDMC,

I hope you and your family had a happy and safe Thanksgiving holiday. Back before the holiday, I asked you to help me decide which of the salary and benefits you would like to have restored if and when the hospital's financial picture rebounds. Remember that back in March, I told you not to expect any restoration through all of FY 2010, so the fact that I am even bringing this up now should be viewed as a relatively positive sign.

Almost 2000 of you responded (a third of those working here), and results were overwhelming:Restore annual salary increase: 65%Restore 401(k) match: 21%Restore full ET accruals: 14%

Thanks for your help in setting our priorities: So that will be our goal, to restart annual salary increases. Here's how I would like it to work. We will look at our financial results late in January and if we are at or better than budget, we will start up raises again. We would do that effective April 1, the date raises stopped last year. That way, it would be much easier to keep track of everything, and everybody would have faced exactly the same period (one year) without an increase. The amount of increase would be 3% if everything goes according to plan, and you would receive it on your regular anniversary date, thereby keeping everyone on par with those who received a 3% increase in the October through March period last year. Managers and supervisors who had their raises revoked as of April 1, 2009 would have them restored effective April 1, 2010.

Regardless of what happens for the larger group of staff, employees in grades 1-4, who received their 3% raise throughout last year, will continue to receive the additional 2% raise announced earlier this year, consistent with our desire to protect those staff members from any gap in salary increases over this time period.

Where are we right now, relative to budget? Well, October was a strong month, and November was a slow month, and December thus far seems about on target. I am cautiously optimistic, but we live in uncertain times, and I am not guaranteeing that we will be able to do this. I will keep you informed over the coming weeks about whether we are able to meet our goal of restoring increases as of April 1st. This does not mean we are giving up on restoring other benefits, but my hope is to start with the salary increases.

Tuesday, December 15, 2009

Students from Marshfield High School visited BIDMC yesterday for brief holiday concerts in several of our public spaces. Thanks to them for taking the time and gracing our halls! (If you cannot view the embedded video here, follow this link to YouTube.)

This follows up on the post below about using networked intelligence to solve complex problems. Our Chief Academic Officer, Vikas Sukhatme, told me about two websites based on this concept.

One is called Innocentive and the other is called Topcoder, the first for inventions of a general nature, the second for software solutions. The idea of formally using the wisdom of the crowd, stimulated by prize money, to solve problems is fascinating and powerful.

Monday, December 14, 2009

Back on October 29, I told you the story of the uninformative signage on the MBTA's Green Line and also mentioned the stern warnings about fare evasion presented to the public on those signs. Well, now I have my new Flip videocam and have documented that warning. But stay tuned till after the warning. Then you get a view of the fare box in my train. The dollar bill payment slot is not functioning, so the driver has inserted a dollar bill into the slot to prevent people from using it.

And who says MTBA riders are not honest? Even as the train pulls away several stops later, you can catch a glimpse of the dollar bill hanging out of the machine, having been left in place by dozens of ethical riders. (If you cannot view the embedded video here, you can follow this link to see it on YouTube.)

As a child of the '60s, I grew up with heroes like Bobby Kennedy and Martin Luther King, Jr. Then in college, we all learned about and were inspired by their precursors, ranging from Thoreau to Gandhi. We studied, too, recent practitioners of the art of community organizing from Saul Alinksy to Cesar Chavez.

I hadn't met Marshall Ganz until I was preparing to introduce him at the IHI National Forum. It was marvelous to meet someone who had been through a parallel journey. While our paths have been different -- his in community organizing and mine in public service -- we have employed many of the same strategies and techniques. More important, I found that we have been motivated by a similar set of values.

Marshall ended his presentation with the famous quote from Hillel, also one of my favorites:

If I am not for myself, who will be for me?If I am only for myself, what am I?And if not now, when?

This followed his impressive speech about the nature of community organizing and, in particular, the importance of having an underlying set of values to serve as the moral basis for a movement.

Having now watched the SEIU for several years, I was struck by the contrast between Marshall's prescriptions and this union's mode of operation. As I listened to his talk, I realized that the union has, in many ways, lost its soul as it has gained power and influence. It has become part of the "they" that is the target of community organizing. Instead of drawing on the resources available to it -- the courage, passion, creativity, and commitment of workers -- it relies on money and power to gain more money and power.

What do I mean, and who, after all, am I to say anything about this? First the latter. I am just someone who cares deeply about the personal and professional development of workers, as well as their economic well-being. I am particularly interested in providing an environment in which those at the lower end of the economic spectrum can succeed in American life. I like to think that my actions and those of our hospital reflect this desire. We have tried to demonstrate it through process improvement approaches that empower all workers, through job training and development programs that give people a step up, and by adopting personnel policies that especially support lower wage workers. We are not perfect at doing all of this, but we do try.

SEIU materials indicate that the union believes in similar things. But the execution of its strategy does not reflect an underlying respect for its constituents that Marshall Ganz makes clear is at the heart of community organizing.

When I watch the SEIU at work, I see an approach more akin to that used by large, powerful corporations. I see union organizing based on trying to stifle debate. I see large amounts of dues-derived dollars being spent on corporate campaigns that denigrate the very work being carried out by the workers. When I talk with SEIU workers from other hospitals, they tell me that they do not feel a close personal connection with the union or the local stewards. When I talk with politicians, they tell me that they feel they have to publicly support the SEIU because of dollars and election-day logistical help; but they say that their support is only skin-deep because they fundamentally do not trust the union. They fear that it will quickly and viciously turn against them if there is a policy disagreement.

Marshall used the story of David and Goliath as an example of how the underdog in a social battle volunteered when no one else would take the charge and used courage and ingenuity to win -- throwing off the constraints and approaches of the old way (Saul's armor) and using the resources available to him (the sling) to surprise a ponderous and overly confident enemy with a small but deadly stone to the forehead. Compare that to the SEIU, which has diverged from those methods and become reliant on the trappings of power to acquire still more trappings of power. The union may or may not be successful in following this path, but in the meantime it will not be able to answer Hillel's three questions in a manner consistent with an underlying set of values that will motivate workers and that is respectful of them.

Sunday, December 13, 2009

When ceramic artist Katya Apekina arrived in the US from Russia, she was virtually unknown here. We purchased one of her works, this pretty Chanukah menorah, in 1992. At the time, most of her pieces were quite small. One of her friends, Francis Putnoi, was introducing her to the art world and advised her to produce larger pieces. She made many of those, some of which are on display as the decor in Newton's Cafe St. Petersburg. Since then she has become very popular. Katya also makes pieces for table tops and other settings, often with a Jewish theme. Here is her website.

I just attended a book party for Andrew McAfee, who has written a great book called Enterprise 2.0 (Harvard Business Press). Here's my blurb for the book:

"Andrew McAfee coined the term Enterprise 2.0 to describe a phenomenon that has changed the way the world does business. Now he takes it a step further. Whether your firm is already deeply embedded in Enterprise 2.0 or you are trying to communicate its value to your staff and your customers, you will soon wear out this book by repeatedly referring to its thoughtful descriptions, advice, and insights."

Here's a view of Andy at the party, courtesy of my new Flip video camera. Uh oh, another addiction!

Saturday, December 12, 2009

There's a site called The Web Nurse with lots of useful information about online training to be a nurse. They recently published a list of "Top Blogs to Learn About Medicine." I was flattered to be included, but then I started looking at the list. Do you see what's missing? There is a not a single blog written from the point of view of patients, by patients, or for patients.

If you look to the right, I have a list of almost 20 excellent ones, especially this one, without trying very hard. Can't a nursing site do better?

I don't think I would have noticed this a year ago, but I have had the message pounded into me by Dave's blog (compounded by a bit of training from IHI's Maureen Bisognano).

Point 2: Symptoms give rise to differing possible diagnoses.

Dave himself was recently invited to speak to the regional San Francisco Healthcare Information and Management Systems Society meeting. He reported to me:

20 minutes into the talk, the lights in the left side of the room went out. Somebody suggested "Motion detector?" Well, there were 50 people on that side of the room, so I didn't think it likely, but I went over and waved my arms, and the lights came on. Since that didn't happen any other time that day, it appears that side was motionless long enough that the sensors thought everyone had gone home. :)

I replied that this indicated one of two things. Either he put everyone to sleep, or they were in rapt attention and therefore not moving. Based on our recent Grand Rounds, I surmised the latter, because I saw the same effect with our doctors. But you never know. Maybe he had a bad day.

Fortunately for Dave's future speaking career, the riddle was solved by a report from Jan Oldenburg of Kaiser, board member of Northern California HIMSS, who organized the event. She said that a board member described the talk as "mesmerizing."

Friday, December 11, 2009

Part of the Red Sox Scholars program is to give the kids exposure to a variety of career opportunities and fields of endeavor as they go through middle school and high school and think about college and beyond. Today, the Class of 2009 came for a view of our medical and surgical Simulation and Skills Center and our NICU. They asked lots of great questions and took notes. (But that was after the pizza.)

This was a text message I received this morning from a grateful patient.

My reply, "Right!"

Here's an example, a note from a person in human resources to the head of our food services:

Good morning Nora,

I would like to applaud two of your wonderful employees, Odalis Lajara and Janaliz Figueroa from the Farr Cafeteria. This morning I went to the café and when I got to the bottom stairwell, I found an elderly woman who looked like she was about to pass out. I asked if she was okay. She stated, "No, I feel like I am going to get sick and I am diabetic." I called over to Odalis and Janaliz and told them in Spanish (the little I know) that she needed something to eat and orange juice to drink. We then had a team rescue going on. Odalis and Janaliz sat her down, I made her an english muffin and retrieved some orange juice for her. Odalis and Janaliz never left her side. We also gave her a banana and some peanut butter crackers.

We had a conversation with her and found out that she flew in from California, She is a patient of Dr. Chu at Joslin. We decided that Janaliz would escort the patient over to Joslin and I would return to work and contact Dr. Chu's office. I left my contact info for Dr. Chu to contact me with Shaka and she in turn would explain this situation to Dr. Chu. It was so wonderful of Odalis and Janaliz to come to the rescue of a grateful patient who in our conversation loves coming here to Boston for all her health care.

Please offer my sincere gratitude to both these employees for knowing that the patient comes first!

Speaking of networks (like below), the largest single source of referrals I have received for this blog is this one, unclutter.com. It appears that lots of people in the world seek help to unclutter their lives! Those that do loyally follow the links on the pages referred to. Above is the listing of the top pages viewed on my blog over the last day or so. Beyond my last two posts, the most popular pages are exactly the ones embedded in the post to which unclutter.com linked.

A great story, here, about the use of social media to solve a difficult computational problem.

The U.S. Defense Department’s Defense Advanced Research Projects Agency (DARPA) was holding a competition that weekend: on Saturday morning, 10 large red weather balloons would be raised at undisclosed locations across the United States; the first team to use social media — like online social networks and communication systems — to determine the correct latitude and longitude of all 10 would receive $40,000.

The crux of the MIT team’s approach was the incentive structure it designed — a way of splitting up the prize money among people who helped find a balloon. Whoever provided the balloon’s correct coordinates got $2,000; but whoever invited that person to join the network got $1,000; whoever invited that person got $500; and so on. No matter how long the chain got, the total payment would never quite reach $4,000; whatever was left over went to charity.

The result:

On Saturday morning the balloons went up, and by the end of the day the MIT team — which consisted of postdocs Riley Crane and Manuel Cebrian and grad students Galen Pickard, Anmol Madan, and Wei Pan — had won the competition.

Thursday, December 10, 2009

“The good news is that I truly outdid myself this year with my Christmas decorations. The bad news is that I had to take him down after two days. I had more people come screaming up to my house than ever. Great stories. But two things made me take it down.

First, the cops advised me that it would cause traffic accidents, as they almost wrecked when they drove by.

Second, a 55-year-old lady grabbed the 75 pound ladder and almost killed herself putting it against my house and didn’t realize that it was fake until she climbed to the top. (She was not happy.) By the way, she was one of the many people who attempted to do that. My yard couldn’t take it either. I have more than a few tire tracks where people literally drove up my yard.”

#IHI09 Following a wrong side surgery a year-and-a-half ago, an interdisciplinary team of our staff revamped our pre-surgical protocol and developed training materials for all OR staff. Here is a sequence of excerpts of recent emails on the topic.

Please rest assured that this doctor is in a distinct minority, at least in our hospital. Unfortunately, I heard reports at the IHI National Forum from people in other hospitals that his view remains all too common elsewhere.

---Surgeons and residents,Dr. Hurst (Acting Chair of Surgery) and I wanted to let you know you must complete this training module. All OR users must do this. . . .

Please click on the link below to go through the module and do the few questions required. Your completion will be recorded in performance manager, but if necessary send your verification e-mail to your supervisor so they can make sure you have been credited with completion. It is required of all attendings and residents using the operating rooms.

This is an important issue for the institution, as it was one of the corrective actions created when we had the wrong site surgery a while back. . . .

I am sending this out today, as there is a proposal being forwarded to the OR Executive Committee to block OR scheduling and resident access to the ORs until the module is completed. In so doing it is hoped we will have significant compliance. . . .

Thanks in advance for your help with this. If at all possible do it today.Don Moorman, Vice Chair

---Reply from one surgeon, sent (probably in error) to the entire mailing list!

Don,I realize you are only the messenger, but in my humble opinion, this is the classic example of “the tail waging the dog”. Because some goofball operated on the wrong side, we now must all engage in this annoying practice every time we operate. It’s that kind of world, I guess. Too bad!

---Response from Doug Hanto, Chief of the Transplantation Division, also sent to the entire mailing list:

I can guarantee you that every surgeon who has operated on the wrong side or left a lap or instrument in a patient never thought it could ever happen to them. These procedures are designed to protect patients from errors that even with the best intentions can happen to the best of us unless we are extra vigilant and have policies and procedures like this in place. . . .

Paul Solman and team won an Emmy this week for outstanding coverage of a current business news story for "Faces Behind the Numbers," a duo of pieces on U.S. unemployment. This series included the story about the “share economy” with interviews of people at of the Beth Israel Deaconess Medical Center staff.

The Journal of Clinical Oncology (JCO) announced that BIDMC's Stephen A. Cannistra, MD, will become Editor-in-Chief of JCO effective May 2011. This was the result of an international search by American Society of Clinical Oncology. The JCO is the most highly regarded oncology specialty journal in the world.

Academic Medicine, the Journal of the Association of American Medical Colleges, published an insightful article about the development of the Center for Quality and Safety at Massachusetts General Hospital.

Wednesday, December 09, 2009

#IHI09 Many thanks to Joanne Healy and Emily Crites for organizing the logistics at the IHI National Forum. Everything went incredibly smoothly as the IHI "blue shirt" team took good care of 5000 people on site over four days in Orlando.

#IHI09 Marshall Ganz was the keynote speaker at this morning's plenary session at the IHI National Forum. As co-chair of the event, I had the privilege of introducing him. See biographical details here. An excerpt: "Marshall entered Harvard College in the fall of 1960. In 1964, a year before graduating, he left to volunteer as a civil rights organizer in Mississippi." And thus began a lifelong career in movement building. (He eventually, 28 years later, went back to conclude his degree.) Before getting into lessons learned, Marshall explained what it was like to be involved in the early days of the civil right movement in the South.

Marshall summarized five practices that constitute leadership for change, which I summarize very briefly here:1) Using storytelling to enable people to act together for change. "Narrative is how we learn to make choices, to understand the world affectively. Stories teach us how to act under uncertainty. We need to learn how to tell stories purposefully."2) Building relationships. "Create a mutual commitment to a common purpose. Association makes the whole greater than the sum of its parts."3) Creating an organizational structure based on team leadership rather than individual leadership. "Establish clear norms of behavior for the teams."4) Translating shared values into action requires a focus on a few strategic objectives. "How to turn what we have into what we need to get what we want. Good strategy flows from commitment. Commitment puts us into a place where we have to figure it out. Use the resources we have, not the ones we don't. Don't buy in to conventional notions.5) Actions to be real have to be real, concrete, and specific, with measurable results. "It matters what we count. There has to be a connection between metrics and strategy. Does the strategy move us towards the goal and increase our capacity to work together, and are people learning and growing as a result of the effort?"

That is a message to the attendees at the session (a repeat of the one below) I am now conducting at the IHI National Forum, entitled Using Social Media to Pursue Quality and Safety. I have asked them to keep their Twitter search open for the meeting hashtag, #IHI09, as an illustration of how quickly information can flow through the social media.

This post is timed to go up at 11:25 am, just after the session starts. My blog posts automatically are fed to Twitter, and the hashtag will ensure that this post is collected by Twitter in the National Forum collection of tweets. The first person in my session to notice the tweet and yell "Eureka" will win a prize.

In the session, I will present our journey at BIDMC in the use of social media in encouraging our programs in patient safety and quality. This all started with some posts on this blog about central line infections, ventilator associated pneumonia, and hand hygiene. We discovered two things from those posts. First, the world would not come to an end if we disclosed clinical outcomes from our hospital. Second, the public presentation of these data acts as a stimulus to quality and safety improvement in the hospital. It serves to hold ourselves accountable to the standard of care we strive for.

Following publication on this blog, we moved to doing the same in a more expanded way on our corporate website. Here, you can see some of the same quality metrics, but you also see the full survey conducted by the Joint Commission when they came to accredit our hospital. Why? Well, the Joint Commission has important things to say about how well we run our place and where we should make improvements. How better for everyone in the hospital to see those things than to post them on the company website?

Each hospital has to decide for itself what degree of transparency is appropriate and comfortable, but as noted by John Toussaint here at the National Forum, it is an essential component of a culture of continuous process improvement. Social media can help spread the world.

Added later: The picture above is of the winner of the prize at this session, Mark Trahant. Congratulations!